ANA Standards of Psychiatric-Mental Health Nursing Practice PDF

Psychiatric- Mental Health Nursing 2ND EDITION ANA Standards of Psychiatric–Mental Health Nursing Practice The Standards of Practice Standards of Practice for for Psychiatric–Mental Health Nursing describe a Psychiatric–Mental Health Nursing competent level of nursing Standard 1. Assessment care as demonstrated by the The PMH registered nurse collects and synthesizes comprehensive health data critical thinking model known that are pertinent to the healthcare consumer’s health and/or situation. as the nursing process. The nursing process Standard 2. Diagnosis includes the components The PMH registered nurse analyzes the assessment data to determine diagnoses, of assessment, diagnosis, problems, and areas of focus for care and treatment, including level of risk. outcomes identification, Standard 3. Outcomes Identification planning, implementation, The PMH registered nurse identifies expected outcomes and the healthcare consumer’s and evaluation. Accordingly, goals for a plan individualized to the healthcare consumer or to the situation. the nursing process encompasses significant Standard 4. Planning actions taken by psychiatric– The PMH registered nurse develops a plan that prescribes strategies and mental health (PMH) alternatives to assist the healthcare consumer in attainment of expected outcomes. registered nurses and forms Standard 5. Implementation the foundation of the nurse’s The PMH registered nurse implements the specified plan. decision-making. Standard 5A. Coordination of Care The PMH registered nurse coordinates care delivery. Standard 5B. Health Teaching and Health Promotion The PMH registered nurse employs strategies to promote health and a safe environment. Standard 5C. Consultation The PMH advanced practice registered nurse provides consultation to influence the identified plan, enhance the abilities of other clinicians to provide services for healthcare consumers, and effect change. Standard 5D. Prescriptive Authority and Treatment The PMH advanced practice registered nurse uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations. Standard 5E. Pharmacological, Biological, and Integrative Therapies The PMH advanced practice registered nurse incorporates knowledge of http://www.apna.org/ pharmacological, biological, and complementary interventions with applied clinical skills to restore the healthcare consumer’s health and prevent further disability. Standard 5F. Milieu Therapy The PMH advanced practice registered nurse provides, structures, and maintains a safe, therapeutic, recovery-oriented environment in collaboration with healthcare consumers, families, and other healthcare clinicians. Standard 5G. Therapeutic Relationship and Counseling The PMH registered nurse uses the therapeutic relationship and counseling interventions to assist healthcare consumers in their individual recovery journeys by improving and regaining their previous coping abilities, fostering mental health, and preventing mental disorder and disability. Standard 5H. Psychotherapy The PMH advanced practice registered nurse conducts individual, couples, http://www.ispn-psych.org/ group, and family psychotherapy using evidence-based psychotherapeutic frameworks and the nurse–client therapeutic relationship. Standard 6. Evaluation The PMH registered nurse evaluates progress toward attainment of expected outcomes. SOURCE: American Nurses Association, American Psychiatric Nurses Association & Interna- http://www.Nursingworld.org tional Society of Psychiatric–Mental Health Nurses (2013). Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2nd Edition. Silver Spring, MD: Nursesbooks.org. © 2014 ANA, APNA, and ISPN Psychiatric- Mental Health Nursing 2nd Edition American Nurses Association Silver Spring, Maryland 2014 American Nurses Association 8515 Georgia Avenue, Suite 400 Silver Spring, MD 20910-3492 1-800-274-4ANA http://www.Nursingworld.org Published by Nursesbooks.org The Publishing Program of ANA http://www.Nursesbooks.org/ The American Psychiatric Nurses Association (APNA), the International Society of Psychiatric-Mental Health Nurses (ISPN), and the American Nurses Association (ANA) are national professional associations. This joint publication, Psychiatric Mental Health Nursing: Scope and Standards of Practice, 2nd Edition, reflects the thinking of the practice specialty of psychiatric-mental health nursing on various issues and should be reviewed in conjunction with state board of nursing policies and practices. State law, rules, and regulations govern the practice of nursing, while Psychiatric Mental Health Nursing: Scope and Standards of Practice, 2nd Edition guides psychiatric-mental health nurses in the application of their professional skills and responsibilities. The American Psychiatric Nurses Association (APNA) is your resource for psychiatric-mental health nursing. A professional organization with more than 9,000 members, we are committed to the practice of psychiatric mental health (PMH) nursing, health and wellness promotion through identification of mental health issues, prevention of mental health problems and the care and treatment of persons with psychiatric disorders. To facilitate professional advancement, APNA provides quality psychiatric-mental health nursing continuing education; a wealth of resources for established, emerging, and prospective PMH nurses; and a community of dynamic collaboration. APNA champions psychiatric-mental health nursing and advocates for mental health care through the development of positions on key issues, the widespread dissemination of current knowledge and developments in PMH nursing, and collaboration with consumer groups, to promote evidence-based advances in recovery-focused assessment, diagnosis, treatment, and evaluation of persons with mental illness and substance use disorders. For more information: www.apna.org. The International Society of Psychiatric-Mental Health Nurses exists to unite and strengthen the presence and the voice of specialty psychiatric-mental health nursing while influencing healthcare policy to promote equitable, evidence-based and effective treatment and care for individuals, families, and communities. http://www.ispn-psych.org The American Nurses Association is the only full-service professional organization representing the interests of the nation’s 3.1 million registered nurses through its constituent/state nurses associations and its organizational affiliates. The ANA advances the nursing profession by fostering high standards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on healthcare issues affecting nurses and the public. Copyright © 2014 American Nurses Association, American Psychiatric Nurses Association and International Society of Psychiatric-Mental Health Nurses. All rights reserved. Reproduction or transmission in any form is not permitted without written permission of the American Nurses Association (ANA). This publication may not be translated without written permission of ANA. For inquiries or to report unauthorized use, email [email protected] ISBN-13: 978-1-55810-556-0 SAN: 851-3481 06/2014 First printing: June 2014 Contents Contributors vii Preface ix Scope of Practice of Psychiatric-Mental Health Nursing 1 Introduction 1 History and Evolution of Psychiatric-Mental Health Nursing 2 Origins of the Psychiatric-Mental Health Advanced Practice Nursing Role 5 Current Issues and Trends 7 Prevalence of Mental Disorders across the Lifespan: Critical Facts 8 Substance Abuse Disorders: Prevalence and Comorbidities 9 Children and Older Adults 10 Disparities in Mental Health Treatment 10 Opportunities to Partner with Consumers for Recovery and Wellness 11 Structure of a Person-Centered, Recovery-Oriented Public Health Care Model: Unifying Efforts 12 Prevention: The Promise of Building Resiliency 12 Screening and Early Intervention 13 Integrated Care 14 Technology of a Public Health Model of Mental Health Care 15 Emerging Models of Acute Care 15 Workforce Requirements for a Public Health Model of Mental Health Care 16 Psychiatric-Mental Health Nursing Leadership in Transforming the Mental Health System 18 Definition of Psychiatric-Mental Health Nursing 18 Phenomena of Concern for Psychiatric-Mental Health Nurses 21 Psychiatric-Mental Health Nursing Clinical Practice Settings 22 Crisis Intervention and Psychiatric Emergency Services 22 Acute Inpatient Care 23 Intermediate and Long-Term Care 23 Partial Hospitalization and Intensive Outpatient Treatment 23 Residential Services 23 Community-Based Care 24 Assertive Community Treatment (ACT) 24 iii Contents Levels of Psychiatric-Mental Health Nursing Practice 24 Psychiatric-Mental Health Registered Nurse (PMH-RN) 25 Psychiatric-Mental Health Advanced Practice Registered Nurse (PMH-APRN) 27 Consensus Model: LACE (Licensure, Accreditation, Certification and Education) and APRN Roles 28 Primary Care 30 Psychotherapy 31 Psychopharmacological Interventions 32 Case Management 32 Program, System, and Policy Development and Management 33 Psychiatric Consultation–Liaison Nursing (PCLN) 33 Clinical Supervision 34 Administration, Education, and Research Practice 35 Self-Employment 35 Other Specialized Areas of Practice 36 Integrative Programs 36 Telehealth 37 Forensic Mental Health 37 Disaster Psychiatric-Mental Health Nursing 37 Ethical Issues in Psychiatric-Mental Health Nursing 38 Respect for the Individual 38 Commitment to the Healthcare Consumer 39 Advocacy for the Healthcare Consumer 39 Responsibility and Accountability for Practice 40 Duties to Self and Others 41 Contributions to Healthcare Environments 41 Advancement of the Nursing Profession 42 Collaboration to Meet Health Needs 42 Promotion of the Nursing Profession 42 Standards of Psychiatric-Mental Health Nursing Practice 43 Standards of Practice for Psychiatric-Mental Health Nursing 44 Standard 1. Assessment 44 Standard 2. Diagnosis 46 Standard 3. Outcomes Identification 48 Standard 4. Planning 50 iv Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Contents Standard 5. Implementation 52 Standard 5A. Coordination of Care 54 Standard 5B. Health Teaching and Health Promotion 55 Standard 5C. Consultation 57 Standard 5D. Prescriptive Authority and Treatment 58 Standard 5E. Pharmacological, Biological, and Integrative Therapies 59 Standard 5F. Milieu Therapy 60 Standard 5G. Therapeutic Relationship and Counseling 62 Standard 5H. Psychotherapy 63 Standard 6. Evaluation 65 Standards of Professional Performance for Psychiatric-Mental Health Nursing 67 Standard 7. Ethics 67 Standard 8. Education 69 Standard 9 Evidence-Based Practice and Research 71 Standard 10. Quality of Practice 73 Standard 11. Communication 75 Standard 12. Leadership 76 Standard 13. Collaboration 78 Standard 14. Professional Practice Evaluation 80 Standard 15. Resource Utilization 82 Standard 16. Environmental Health 84 Glossary 87 References 93 Abbreviations 107 Appendix A. Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2007) 109 Index 171 Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E v Contributors APNA and ISPN Joint Task Force Members Kris A. McLoughlin, DNP, APRN, PMHCNS-BC, CADC-II, FAAN—APNA Co-Chair Catherine F. Kane, PhD, RN, FAAN—ISPN Co-Chair Kathleen Delaney, PhD, PMH-NP, FAAN Sara Horton-Deutsch, PhD, APRN, PMHCNS, RN, ANEF Amanda Du Wick, BSN, RN-BC Kay Foland, PhD, RN, PMHNP-BC, PMHCNS-BC, CNP Susan L.W. Krupnick MSN, PMHCNS-BC, ANP-BC, C-PREP Sue M. Odegarden, MA, MS, BSN Bethany J. Phoenix, PhD, RN, CNS Peggy Plunkett, MSN, APRN, PMHCNS-BC Diane Snow, PhD, RN, PMHNP-BC, CARN, FAANP Victoria Soltis-Jarrett, PhD, PMHCNS/NP-BC Christine Tebaldi, MSN, APRN, PMHNP-BC Edilma L. Yearwood, PhD, PMHCNS-BC, FAAN ANA Staff Carol J. Bickford, PhD, RN-BC, CPHIMS—Content editor Maureen E. Cones, Esq.—Legal counsel Yvonne Daley Humes, MSA—Project coordinator Eric Wurzbacher, BA—Project editor About the American Psychiatric Nurses Association The American Psychiatric Nurses Association (APNA) is your resource for psychiatric‑mental health nursing. A professional organization with more than 9,000 members, we are committed to the practice of psychiatric‑mental health (PMH) nursing, health and wellness promotion through identification of mental health issues, prevention of mental health problems and the care and treatment of persons with psychiatric disorders. To facilitate professional advancement, APNA provides quality psychiatric-mental health nursing continuing education; a wealth of resources for established, emerging, and vii CONTRIBUTORS prospective PMH nurses; and a community of dynamic collaboration. APNA champions psychiatric-mental health nursing and advocates for mental health care through the development of positions on key issues, the widespread dissemination of current knowledge and developments in PMH nursing, and collaboration with consumer groups, to promote evidence-based advances in recovery-focused assessment, diagnosis, treatment, and evaluation of persons with mental illness and substance use disorders. For more information: www. apna.org. About the International Society of Psychiatric-Mental Health Nurses The International Society of Psychiatric-Mental Health Nurses (ISPN) exists to unite and strengthen the presence and the voice of specialty psychiatric- mental health nursing while influencing healthcare policy to promote equitable, evidence-based and effective treatment and care for individuals, families, and communities. http://www.ispn-psych.org About the American Nurses Association The American Nurses Association (ANA) is the only full-service professional organization representing the interests of the nation’s 3.1 million registered nurses through its constituent/state nurses associations and its organizational affiliates. The ANA advances the nursing profession by fostering high standards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on health care issues affecting nurses and the public. About Nursesbooks.org, The Publishing Program of ANA Nursesbooks.org publishes books on ANA core issues and programs, including ethics, leadership, quality, specialty practice, advanced practice, and the profession’s enduring legacy. Best known for the foundational documents of the profession on nursing ethics, scope and standards of practice, and social policy, Nursesbooks.org is the publisher for the professional, career-oriented nurse, reaching and serving nurse educators, administrators, managers, and researchers as well as staff nurses in the course of their professional development. viii Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Preface In 2011, the American Psychiatric Nurses Association (APNA) and the International Society of Psychiatric-Mental Health Nurses (ISPN) appointed a joint task force to begin the review and revision of Psychiatric-Mental Health Nursing: Scope and Standards of Practice, published in 2007 by the American Nurses Association (ANA, 2007). The taskforce members were comprised of psychiatric-mental health nursing clinical administrators, staff nurses, nursing faculty, and psychiatric advanced practice registered nurses working in psychiatric facilities and the community. This taskforce convened in July 2011 to conduct an analysis of the existing document and begin crafting sections incorporating the results of the analysis. In accordance with ANA recommendations, this document reflects the template language of the most recent publication of ANA nursing standards, Nursing: Scope and Standards of Practice, Second Edition (ANA, 2010). In addition, the introduction has been revised to highlight the leadership role of psychiatric-mental health nurses in the transformation of the mental health system as outlined in Achieving the Promise, the President’s New Freedom Commission Report on Mental Health (United States Department of Health and Human Services, 2003) and the Institute of Medicine’s Report (IOM) The Future of Nursing (2010). The prevalence of mental health issues and psychiatric disorders across the age span, and the disparities in access to care and treatment among diverse groups attest to the critical role that psychiatric- mental health (PMH) nursing must continue to play in meeting the goals for a healthy society. Safety issues for persons with psychiatric disorders and the nurses involved in the recovery processes of persons with mental disorders are major priorities for PMH nursing in an environment of fiscal constraints and disparities in reimbursement for mental health services. Development of this edition of Psychiatric-Mental Health Nursing: Scope and Standards of Practice included a two-stage field review process: 1) review and feedback from the boards of the American Psychiatric Nurses Association and the International Society of Psychiatric-Mental Health Nursing and 2) posting of the draft for public comment at www.ISPN-psych.org with links from the ANA website, www.nursingworld.org, and the APNA website, www. apna.org. Notice of the public comment period was distributed to nursing specialty organizations, state boards of nursing, nursing schools, faculty groups, ix PREFACE and state nurses associations. All groups were encouraged to disseminate notice of the postings to all of their members and other stakeholders. The feedback was carefully reviewed and integrated when appropriate. x Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Scope of Practice of Psychiatric-Mental Health Nursing Psychiatric-mental health nursing is the nursing practice specialty committed to promoting mental health through the assessment, diagnosis, and treatment of behavioral problems, mental disorders, and comorbid conditions across the lifespan. Psychiatric-mental health nursing intervention is an art and a science, employing a purposeful use of self and a wide range of nursing, psychosocial, and neurobiological evidence to produce effective outcomes. Introduction By developing and articulating the scope and standards of professional nursing practice, the nursing profession both defines its boundaries and informs society about the parameters of nursing practice. The scope and standards also guide the development of state level nurse practice acts and the rules and regulations governing nursing practice. Because each state develops its own regulatory language about nursing, the designated limits, functions, and titles for nurses, particularly at the advanced practice level, may differ significantly from state to state. Nurses must ensure that their practice remains within the boundaries defined by their state practice acts. Individual nurses are accountable for ensuring that they practice within the limits of their own competence, professional code of ethics, and professional practice standards. Levels of nursing practice are differentiated according to the nurse’s educational preparation. The nurse’s role, position, job description, and work setting further define practice. The nurse’s role may be focused on clinical practice, administration, education, or research. This document addresses the role, scope of practice, and standards of practice specific to psychiatric-mental health nursing. The scope statement defines psychiatric-mental health nursing and describes its evolution in nursing, the 1 Scope OF Practice of PSYCHIATRIC–MENTAL HEALTH NURSING levels of practice based on educational preparation, current clinical practice activities and sites, and current trends and issues relevant to the practice of psychiatric-mental health nursing. The standards of psychiatric-mental health nursing practice are authoritative statements that describe the responsibilities for which its practitioners are accountable. History and Evolution of Psychiatric-Mental Health Nursing Psychiatric-mental health nursing began with late 19th century reform move- ments to change the focus of mental asylums from restrictive and custodial care to medical and social treatment for the mentally ill. The “first formally organized training school within a hospital for insane in the world” was established by Dr. Edward Cowles at McLean Asylum in Massachusetts in 1882 (Church, 1985). The use of trained nurses, rather than “keepers,” was central to Cowles’ effort to replace the public perception of “insanity” as deviance or infirmity with a belief that mental disorders could be ameliorated or cured with proper treatment. The McLean nurse training school was the first in the United States to allow men the opportunity to become trained nurses (Boyd, 1998). Eventually, asylum nursing programs established affiliations with general hospitals so that general nursing training could be provided to their students. Early on, training for psychiatric nurses was provided by physicians. The first nurse-organized training course for psychiatric nursing within a general nursing education program was established by Effie Jane Taylor at Johns Hopkins Hospital in 1913 (Boyd, 1998). This course served as a prototype for other nursing education programs. Taylor’s colleague Harriet Bailey published the first psychiatric nursing textbook, Nursing Mental Disease, in 1920 (Boling, 2003). Under nursing leadership, psychiatric-mental health nursing developed a biopsychosocial approach with specific nursing methods for individuals with mental disorders. The PMH nurse also began to identify the didactic and clinical components of training needed to care for persons with mental disorders. In the post-WWI era, “nursing in nervous and mental diseases” was added to curriculum guides developed by the National League for Nursing Education and was eventually required in all educational programs for registered nurses (Church, 1985). The next wave of mental health reform and expansion in psychiatric nursing began during World War II. The public health significance of mental disorders became widely apparent when a significant proportion of potential military 2 Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Scope OF PRACTICE of PSYCHIATRIC–MENTAL HEALTH NURSING recruits were deemed unfit for service as a result of psychiatric disability. In addition, public attention and sympathy for the large number of veterans with combat-related neuropsychiatric casualties led to increased support for improving mental health services. As a psychiatric nurse consultant to the American Psychiatric Association, Laura Fitzsimmons evaluated educational programs for psychiatric nurses and recommended standards of training. These recommendations were supported by professional organizations and backed with federal funding to strengthen educational preparation and standards of care for psychiatric nursing (Silverstein, 2008). The national focus on mental health, combined with admiration for the heroism shown by nurses during the war, led to the inclusion of psychiatric nursing as one of the core mental health disciplines named in the National Mental Health Act (NMHA) of 1946. This act greatly increased funding for psychiatric nursing education and training (Silverstein, 2008) and led to a growth in university-level nursing education. In 1954, Hildegard Peplau established the first graduate psychiatric nursing program at Rutgers University. The post-war era was marked by growing professionalization in psychiatric-mental health nursing (PMH). Funding provided by the NMHA led to a rapid expansion of graduate programs and the start of psychiatric-mental health nursing research. In 1963, the first journals focused on psychiatric- mental health nursing were published. In 1973, the ANA first published the Standards of Psychiatric-Mental Health Nursing Practice and began certify- ing generalists in psychiatric-mental health nursing (Boling, 2003). Peplau’s Interpersonal Relations in Nursing (1992), which emphasized the importance of the therapeutic relationship in helping individuals to make positive behavior changes, articulated the predominant psychiatric-mental health nursing approach of the period. The process of deinstitutionalization began in the late 1950s when the majority of care for persons with psychiatric illness began to shift away from hospitals and toward community settings. Contributing factors included the establishment of Medicare and Medicaid, changing rules governing involuntary confinement, and the passage of legislation supporting construction of community mental health centers (Boling, 2003). Although psychiatric-mental health nurses prepared at the undergraduate level continued to work primar- ily in hospital-based and psychiatric acute care settings, many also began to practice in community-based programs such as day treatment and assertive community treatment. Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E 3 Scope OF Practice of PSYCHIATRIC–MENTAL HEALTH NURSING Mental health care in the United States began another transformation in the 1990s, the “Decade of the Brain.” The dramatic increase in the number of psychiatric medications on the market, combined with economic pressures to reduce hospital stays, resulted in briefer psychiatric hospitalizations characterized by use of medication to stabilize acute symptoms. Shorter hospital stays and higher patient acuity began to shift psychiatric nursing practice away from the emphasis on relationship-based care advocated by Peplau and toward interventions focused on stabilization and immediate safety. Psychiatric-mental health nursing education began to include more content on psychopharmacology and the pathophysiology of psychiatric disorders. More recent trends in psychiatric-mental health nursing include an emphasis on integrated care and treatment of those persons with co-occurring psychiatric and substance use disorders, as well as integrated care and treatment of those with co-occurring medical and psychiatric disorders. Integrated care emphasizes that both types of disorders are primary and must be treated as such. Since the Substance Abuse and Mental Health Services Administration (SAMHSA) has declared that recovery is the single most important goal in the transformation of mental health care in America (SAMHSA, 2006), psychiatric-mental health nursing is moving to integrate person-centered, recovery-oriented practice across the continuum of care. This continuum includes settings where psychiatric-mental health nurses have historically worked, such as hospitals, as well as emergency rooms, jails and prisons, and homeless outreach services. Psychiatric-mental health nursing is also tasked with developing and applying innovative approaches in caring for the large population of military personnel, veterans, and their families experiencing war-related mental health conditions as a result of military conflicts. Major developments in the nursing profession have a corresponding effect within psychiatric-mental health nursing. The Institute of Medicine’s (2010) report, The Future of Nursing: Leading Change to Advance Health has strengthened the role of psychiatric-mental health nurses as mental health policy and program development leaders in both national and international arenas. Nursing’s emphasis on the use of research findings to develop and implement evidence-based practice is driving improvements in psychiatric- mental health nursing practice. 4 Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Scope OF PRACTICE of PSYCHIATRIC–MENTAL HEALTH NURSING Origins of the Psychiatric-Mental Health Advanced Practice Nursing Role Specialty nursing at the graduate level began to evolve in the late 1950s in response to the passage of the National Mental Health Act of 1946 and the creation of the National Institute of Mental Health in 1949. The National Mental Health Act of 1946 identified psychiatric nursing as one of four core disciplines for the provision of psychiatric care and treatment, along with psychiatry, psychology, and social work. Nurses played an active role in meeting the growing demand for psychiatric services that resulted from increasing awareness of post-war mental health issues (Bigbee & Amidi-Nouri, 2000). The prevalence of “battle fatigue” led to recognizing the need for more mental health professionals. The first degree in psychiatric-mental health nursing, a master’s degree, was conferred at Rutgers University in 1954 under the leadership of Hildegard Peplau. In contrast to existing graduate nursing programs that focused on developing educators and consultants, graduate education in psychiatric-mental health nursing was designed to prepare nurse therapists to assess and diagnose mental health problems and psychiatric disorders and provide individual, group, and family therapy. Psychiatric nurses pioneered the development of the advanced practice nursing role and led efforts to establish national certification through the American Nurses Association. The Community Mental Health Centers Act of 1963 facilitated the expansion of psychiatric-mental health clinical nurse specialist (PMHCNS) practice into community and ambulatory care sites. PMHCNSs with master’s and doctoral degrees fulfilled a crucial role in helping deinstitutionalized mentally ill persons adapt to community life. Traineeships to fund graduate education provided through the National Institute of Mental Health played a significant role in expanding the PMHCNS workforce. By the late 1960s, PMHCNSs provided individual, group, and family psychotherapy in a broad range of settings and obtained third-party reimbursement. PMHCNSs also functioned as educators, researchers, and managers, and worked in consultation-liaison positions or in the area of addictions. These roles continue today. Another significant shift occurred as research renewed the emphasis on the neurobiologic basis of mental disorders, including substance use disorders. As more efficacious psychotropic medications with fewer side effects were developed, psychopharmacology assumed a more central role in psychiatric treatment. The role of the PMHCNS evolved to encompass the expanding biopsychosocial perspective, and the competencies required for practice Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E 5 Scope OF Practice of PSYCHIATRIC–MENTAL HEALTH NURSING were kept congruent with emerging science. Many psychiatric-mental health graduate nursing programs added neurobiology, advanced health assessment, pharmacology, pathophysiology, and the diagnosis and medical management of psychiatric illness to their curricula. Similarly, preparation for prescriptive privileges became an integral part of advanced practice psychiatric-mental health nursing graduate programs (Kaas & Markley, 1998). Other trends in mental health and the larger healthcare system also sparked significant changes in advanced practice psychiatric nursing. These trends included: A shift in National Institute of Mental Health (NIMH) funds from education to research, leading to a dramatic decline in enrollment in psychiatric nursing graduate programs (Taylor, 1999); An increased awareness of physical health problems in mentally ill persons living in community settings (Chafetz et al., 2005); A shift to primary care as a key point of entry for comprehensive health care, including psychiatric care; and The growth and public recognition of the nurse practitioner role in primary care settings. In response to these challenges, psychiatric nursing graduate programs modified their curricula to include greater emphasis on comprehensive health assessment, referral, and management of common physical health problems, and a continued focus on educational preparation to meet the state criteria and professional competencies for prescriptive authority. The tremendous expansion in the use of “nurse practitioners” in primary care settings had made nurse practitioner (NP) synonymous with “advanced practice registered nurse” in some state nurse practice acts and for many in the general public. In response to conditions including public recognition of the role, market forces, and state regulations, psychiatric-mental health nursing began utilizing the Nurse Practitioner title and modifying graduate psychiatric nursing programs to conform to requirements for NP credentialing (Wheeler & Haber, 2004; Delaney et al., 1999). The Psychiatric-Mental Health Nurse Practitioner role was clearly delineated by the publication of the Psychiatric-Mental Health Nurse Practitioner Competencies (National Panel, 2003), the product of a panel with representation from a broad base of nursing organizations sponsored by the National Organization of Nurse Practitioner Faculty (NONPF). 6 Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Scope OF PRACTICE of PSYCHIATRIC–MENTAL HEALTH NURSING Whether practicing under the title of clinical nurse specialist (CNS) or NP, Psychiatric-Mental Health Advanced Practice Registered Nurses share the same core competencies of clinical and professional practice. Although psychiatric- mental health nursing is moving toward a single national certification for new graduates of advanced practice programs, titled Psychiatric-Mental Health Nurse Practitioner, persons already credentialed as Psychiatric-Mental Health Clinical Nurse Specialists will continue to practice under this title (NCSBN Joint Dialogue Group Report, 2008). Current Issues and Trends Since the publication of the landmark report Achieving the Promise: Transforming Mental Health Care in America (DHHS, 2003), mental health professionals have been sensitized to the need for a recovery-oriented mental health system. Further, in 2010, SAMHSA approved awards to five national behavioral healthcare provider associations, including the American Psychiatric Nurses Association, to promote awareness, acceptance, and adop- tion of recovery-based practices in the delivery of mental health services. This theme of integrating recovery in practice has been echoed in Leading Change, SAMHSA’s (2011) most recent statement on federal priorities in mental health. Here recovery is endorsed as the essential platform for treatment, along with seven other foci: prevention, health reform, health information technology (IT), data/quality and outcomes, trauma and justice, military families, and public awareness and support. These themes are echoed in important reports from the Centers for Disease Control and Prevention (CDC) and the Institute of Medicine, and have been endorsed by consumer groups. The current mental health treatment landscape has also been shaped by multiple legislative and economic developments. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that has and is expected to continue to favorably affect the quality of care for individuals with mental and substance use disorders. The MHPAEA prevents group health plans and health insurance issuers that provide mental health and substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations for MH/SUD benefits than on medical/surgical coverage. Thus, this vulnerable and highly stigmatized population will have equivalent MH/SUD benefits to those that are provided for general medical treatment. Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E 7 Scope OF Practice of PSYCHIATRIC–MENTAL HEALTH NURSING Another important development is the Patient Protection and Affordable Care Act (PPACA) that brought, among other transformational changes, the promise of expanded healthcare coverage and an assessment of the current system’s capacity to address anticipated demand. In the midst of launching this landmark policy, the economic downturn reverberated through federal and state budgets, which created immediate impacts on mental health services and became a harbinger of a decade of fiscally conservative policies (National Alliance on Mental Illness, 2011). Another major focusing event was the publication of data on the medical comorbidities and decreased life expectancy of individuals with serious mental illness (McGuire et al., 2002). These data hastened the movement toward integrated behavioral/primary care with the Centers for Medicare and Medicaid Services (CMS) monies rapidly shifting to fund innovations in integrated care delivery. The mental health initiatives of the PPACA and SAMHSA are also affected by the triple aim of the broader federal policy agenda: improving the experience of care, improving the health of populations, and reducing per capita costs of health care (Berwick, Nolan, & Whittington, 2008). This shift is accompanied by significant payment reform (most prominently the return of case based and capitation models) and a call for partnership with healthcare consumers (Onie, Farmer, & Behforouz, 2012). This federal focus is finding its way into mental health care, particularly via initiatives to move Medicare and Medicaid into a capitated system (Manderscheid, 2012). This shifting reimbursement structure reflects the realization that engineering a significant impact on the mental health of individuals demands building healthy communities that increase support, reduce disparities, and promote the resiliency of members. This 21st century mental healthcare system must be equally focused on prevention, quality, an integrated approach to health, and a paradigm shift that puts mental health care into the hands of the consumer. Prevalence of Mental Disorders across the Lifespan: Critical Facts Despite the promise of recovery, the prevalence of mental disorders continues to impose a significant burden on individuals, families, and society. According to 2008 SAMHSA data, during the preceding year, an estimated 9.8 million adults aged 18 and older in the United States had a serious mental disorder and 2 million youth aged 12 to 17 had a major depressive episode. More recent incidence data (CDC, 2011) indicate that 6.8% of U.S. adults had a diagnosable episode of depression during the 2 weeks before the survey was administered. In a multi-state survey spanning 2-year collection points, the reported rates of 8 Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Scope OF PRACTICE of PSYCHIATRIC–MENTAL HEALTH NURSING lifetime depression were similar in 2006 (15.7%) and 2008 (16.1%). The prevalence of lifetime diagnosis of anxiety disorders was 11.3% in 2006 and 12.3% in 2008. Finally in 2007, the National Health Interview Survey data on lifetime diagnosis of bipolar disorder and schizophrenia indicated that 1.7% of participants had received a diagnosis of bipolar disorder, and 0.6% had received a diagnosis of schizophrenia (CDC, 2011). Although the prevalence of mental disorders remains high, treatment rates are distressingly low. In 2010, fewer than 40% of the 45.9 million adults with mental disorders had received any mental health services. The figure only improved slightly for those individuals with serious mental illness (SMI). Approximately 60% of the 11.4 million adults with SMI in the prior year had received treatment (SAMHSA, 2012). In 2006, increased mortality was found to be coupled with high prevalence of chronic medical conditions in individuals with mental health issues (Parks, Svendsen, Singer, & Forti, 2006). Further study indicated that, on average, people with SMI die 25 years earlier than those without these illnesses, and little of that increased mortality is attributable to direct effects of the SMI (Prince et al., 2007). These findings lent increased urgency to the call for integration of medical and mental health services (Manderscheid, 2010). In addition to premature mortality, Scott et al. (2009) found that comorbidity of chronic physical and mental disorders creates a synergistic impact on disability, thus supporting the need to give both mental and physical conditions equal prior- ity in order to adequately manage comorbidity and reduce disability. These comorbidities significantly increase healthcare costs (Melek & Norris, 2008), with only a small fraction of those costs (16%) attributable to mental health services. Estimates show that 2.8 million citizens in the United States are dealing with problems related to substance use. This figure is expected to double in 2020, particularly in adults over 50, casting specific concerns for the older adult population (Han, Gfroerer, Colliver, & Penne, 2009). Substance Abuse Disorders: Prevalence and Comorbidities High rates of substance use disorders (SUD) and co-occurring serious mental disorders are also of great concern. The National Drug Use and Health survey estimates that 25.7% of adults with SMI had co-occurring dependence or abuse of either illicit drugs or alcohol (SAMHSH, 2009). This figure puts co-occurring substance use disorders among individuals with SMI at a rate nearly four times higher than SUD in the general population (SAMHSH, 2012). These individuals, particularly persons dealing with co-occurring SUD Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E 9 Scope OF Practice of PSYCHIATRIC–MENTAL HEALTH NURSING and major depression or post-traumatic stress disorder (PTSD), demonstrate poorer life outcomes (Najt, Fusar-Poli, & Brambilla, 2011) such as increased disability and higher suicide rates. Children and Older Adults Prevalence of psychiatric disorders in children is not as well documented as it is in the adult population. It is estimated that approximately 13% of children ages 8 to 15 had a diagnosable mental disorder within the previous year (Merikangas et al., 2010). The 12-month prevalence estimates for specific disorders of children range from a high of 8.6% for attention deficit/hyperactivity disorder to a low of 0.1% for eating disorders (Merikangas et al., 2010). Similarly, the prevalence estimate of any Diagnostic and Statistical Manual, 4th Edition (DSM-IV) disorder among adolescents is 40.3% at 12 months (79.5% of lifetime cases); the most common disorder among adolescents is anxiety, followed by behavior, mood, and substance use disorders (Kessler et al., 2012). Approximately 10.8% of the older adult population had some form of mental distress in 2009, and half of nursing home residents carried a psychiatric diagnosis (SAMHSA, 2009). This prevalence does not include cognitive impairments and dementias like Alzheimer’s disease, the most common of these impairments (New Freedom Commission on Mental Health, 2003). Considering that in 2030, 20% of United States residents will be 65 years or older (Vincent & Velkoff, 2010), the need for mental health services for this population will continue to increase (SAMHSA 2009, 2012). Disparities in Mental Health Treatment Data from the U.S. Census Bureau (2004) demonstrate significant changes in the racial and ethnic composition of the U.S. population. Most significant is the steady increase in the Hispanic or Latino population, which rose to 12.6% in 2000 and will likely rise to 30.2% in 2050 (Shrestha & Heisler, 2011). Although rates of mental disorders in minority populations are estimated to be similar to those in the white population, minorities are less likely to receive mental health services for many reasons, including financial, affective, cognitive, and access barriers (Leong & Kalibatseva, 2012). Efforts to improve quality and access to mental health services for minority populations will need to include greater emphasis on expanding outreach to ethnic communities, developing cultural awareness and sensitivity among individual mental healthcare providers, and increasing cultural sensitivity in healthcare organizations. Barriers to social inclusion, as well as barriers to accessible, effective, and coordinated treatment, contribute to health disparities within the entire 10 Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Scope OF PRACTICE of PSYCHIATRIC–MENTAL HEALTH NURSING population (Institute of Medicine, 2005). Financial barriers include lack of parity in insurance coverage for psychiatric-mental health care and treatment, resulting in restrictions on the number and type of outpatient visits, limits on the number of covered inpatient days, and high co-pays for services. The payment changes anticipated by the PPACA, particularly the expansion of Medicaid to 133% of persons above the poverty level, are likely to bring more individuals into the mental health system. However, the probability of receiving actual treatment may be affected by barriers such as scarcity and maldistribution of mental health providers. Geographical barriers include lack of affordable, accessible public transportation in urban areas and lack of accessible clinical services in rural areas. Cultural issues, including lack of knowledge, fear of treatment, and stigma associated with mental disorder, also constitute barriers to seeking help for mental health problems. Though growing evidence shows the effectiveness of treatment for behavioral problems and psychiatric disorders, these disparities necessitate further efforts to improve access to mental health services. Opportunities to Partner with Consumers for Recovery and Wellness The growing demand for coordinated, cost-effective psychiatric-mental health nursing presents the opportunity to be creative in developing psychiatric-mental health registered nurse (PMH-RN) roles in care coordination, enhanc- ing psychiatric-mental health advanced practice registered nurse (PMH-APRN) roles in integrated care, and developing service delivery models that align with what consumers want. The reimbursement shift away from fee for service and toward caring for populations creates incentives to develop non-traditional services that may have greater effectiveness in supporting the mental health of individuals and families and the construction of healthy communities. The focus on recovery supports PMH traditions of relationship-based care where the focus is on the care and treatment of the person with the disorder, not the disorder itself. By using therapeutic interpersonal skills, PMH-RNs are able to assist persons with mental disorders in achieving their own individual recovery and wellness goals. Research specific to recovery-oriented PMH nursing practices is beginning to emerge. However, more of this research needs to be conducted in varied care and treatment settings and specific outcomes must be connected to recovery-oriented nursing interventions (McLoughlin & Fitzpatrick, 2008). At the systems level, current developments offer opportunities for psychiatric-mental health nurses to connect to the broader nursing and Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E 11 Scope OF Practice of PSYCHIATRIC–MENTAL HEALTH NURSING healthcare community to achieve a public health model of mental health care. In such a model, individuals would receive mental health and substance use interventions at multiple points of connection with the healthcare delivery system and the system would aim to match the intensity of service with the intensity of need. The vision must aspire to create a person-centered mental health system where prevention efforts are balanced with attention to individuals with serious mental disorders. Such a vision will require unifying nurses from a wide range of specialties to create the structure for integrated care; it will also involve constructing consumer-centered outcome evaluation strategies so that all efforts are aligned with the individual goals of the person seeking care or treatment. Structure of a Person-Centered, Recovery-Oriented Public Health Care Model: Unifying Efforts Prevention: The Promise of Building Resiliency In 2009, the Institute of Medicine released its report Preventing Mental, Emotional and Behavioral Disorders among Young People: Progress and Possibilities (O’Connell, Boat, & Warner, 2009). The report contained a landmark synthesis of what was known about the onset of mental disorder, risk factors, environmental influences, and how prevention was possible through strengthening protective factors and reducing risk factors. The report also provided a systematic review of the science of the prevention of mental disorders, articulating the promise of developmental neuroscience not only to map the possible origins and courses of disorders, but also to demonstrate how prevention and early intervention might build resiliency. Clearly, the future of mental health must be grounded in prevention, on platforms of effective programs such as newborn home visiting for at-risk mothers, early childhood interventions, increasing children’s social and emotional skills, and creating social supports within communities (Beardslee, Chien, & Bell, 2011). This paradigm shift has profound implications for PMH nurses, particularly in regard to their work with children and adolescents and their families. Creating a prevention-oriented mental health system will demand that PMH nurses, pediatric nurses, and family nurses understand the science base that supports prevention and the scientific principles aimed at helping children achieve regulation and build resiliency (Greenberg, 2006). Further, it is essential that nurses communicate how a shared science base will help nurses refine interventions that are applicable in both primary care and mental health care (Yearwood, Pearson, & Newland, 2012). 12 Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Scope OF PRACTICE of PSYCHIATRIC–MENTAL HEALTH NURSING Understanding the interplay of environment and risk has implications for SMI prevention throughout the lifespan. Such an approach recognizes the multiple determinants of mental health, risk, and protective factors (WHO, 2004). In a report about global initiatives on prevention, the World Health Organization (WHO) carefully traced the relationship of SMI to social problems, particularly poverty, as well as the relationship of SMI to nutritional, housing, and occupational issues. Prevention, therefore, relies on impacting social determinants of health and reducing the impact of factors that increase risk, such as poverty and abuse/trauma (Onie, Farmer, & Behforouz, 2012). An increasingly important emphasis is placed on strengthening the health of communities, which empowers and supports individuals, as well as builds protective connectivity. Screening and Early Intervention Evidence that roughly half of all lifetime mental health disorders start in the mid-teens (Kessler et al., 2007) increases the need for screening and early intervention in children and adolescents. The synergy of prevention and developmental neuroscience is progressing, particularly at the juncture where early intervention targets psychological processes relevant to the origins of particular mental disorders (March, 2009). Evidence-based programs are increasingly emerging to address early signs of anxiety, depression, and conduct issues in children and teens (Delaney & Staten, 2010). The profound impact of early adverse childhood events (ACE) such as family dysfunction and abuse on an individual’s mental and physical health throughout the lifespan is well documented (Felitti et al., 1998) and informs innovative programs for addressing early trauma and its impact (Brown & Barila, 2012). Screening and early intervention is critical throughout the lifespan, requiring shifting attention away from pathology and dysfunction and toward optimal functioning. Recent recommendations include depression screening in primary care when practices have the capacity for depression care support (USPSTF, 2012). There is increasing interest in prevention of depression relapse and the possible mechanisms that may limit its all too frequent occurrence (Farb, Anderson, Block, & Siegel, 2012). Embedding screening and early intervention into practice will require shifting attention away from pathology and dysfunction and toward optimal functioning. Psychiatric nursing will be pivotal in weaving together the emerging neuroscience that supports building resiliency and the evidence-based practices that support early intervention. Their efforts Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E 13 Scope OF Practice of PSYCHIATRIC–MENTAL HEALTH NURSING must extend to building communication networks with nurses in primary care specialties to create prevention efforts that span disciplinary silos. Integrated Care Several promising initiatives, such as the Penn Resiliency program for teenage depression, demonstrate how to structure early intervention as signs of mental distress are emerging. In this program, using a cognitive behavioral therapy (CBT) approach, preadolescents are taught how to challenge negative thinking; i.e., by evaluating the accuracy of the thought, assessing the evidence to support it, and then devising an alternate response. This program has been implemented in a variety of settings, including schools. In program outcomes across 13 studies, data demonstrate that intervention prevents symptoms of anxiety and depression (Gillham & Reivich, n.d.). Healthcare systems, such as Intermountain Healthcare, have developed scales for systematically screening healthcare consumers; after the assessment, professionals complete a Mental Health Integration form based on the scale scores. The healthcare consumer is then assigned a level of treatment that matches her or his level of service need (Intermountain Healthcare, 2009). Such secondary prevention efforts of school-based health centers and large primary care organizations such as Intermountain must become the norm if APRNs are to engineer systems where persons are treated holistically, and mental health and medical needs are systematically acknowledged with equal vigor. This effort will demand that nurses see themselves as one workforce while recognizing the unique skills that each specialty contributes to the team. Problems such as high costs, fragmentation, gaps in coverage and care, and tendency to deliver care in highly specialized subsystems in the United States healthcare system have provided momentum to the movement toward an integrated care system. Integrated care involves caring for the whole person in a single place, an organization of services that is both more effective and less costly (Manderscheid, 2012). Manderscheid (2012) believes the pace of organizational change to accommodate integrated care is accelerating “like snow in an avalanche.” Initially, models of integrated care called for variations in co- location of services where the emphasis of treatments depended on the needs of the population (National Council for Community Behavioral Healthcare, 2009; Parks et al., 2005). These diverse and evolving models rely on technology and innovations such as integrated services in healthcare homes (Collins, Hewson, Munger, & Wade, 2010). Psychiatric nurses, who always remain close to the needs of the consumer, must ensure that as systems of integrated care 14 Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Scope OF PRACTICE of PSYCHIATRIC–MENTAL HEALTH NURSING are constructed, there is a parallel effort to ensure that individuals can access them, are not intimidated by them, and know how to make the most of the services offered (Geis & Delaney, 2011). Integration should also be guided by the voice of consumers who outline how to build systems on collaboration, effective communication, use of peer navigators, and the critical support of family and community members (CalMed, 2011). Technology of a Public Health Model of Mental Health Care Healthcare technology will be expanded in the coming decade via the increasing use of telehealth and Internet-delivered services, the rising prevalence of Health Information Technology (HIT) to connect service sectors and build care coordination, and the integration of data systems to track outcomes and engineer rapid quality improvement. In their vision for the use of health information technology, SAMHSA (2011) plans innovation support of HIT and the electronic health record (EHR) to reach a 2014 goal of behavioral health care interoperating with primary care. Within this initiative are plans for developing the infrastructure for an interoperable EHR and addressing the accompany- ing privacy, confidentiality, and data standards. Such information exchange is anticipated to integrate care, contain costs, and increase consumers’ control of their personal health care and health information. Internet-delivered behavioral health interventions, such as online cognitive- behavioral treatments for depression and anxiety, are rapidly being developed, which continues to clarify their key elements and outcomes (Bastelaar et al., 2011; Bennett & Glasgow, 2009). Rapid growth in Internet behavioral health treatment is likely to continue, and must address the challenge of creating interventions with fidelity to the framework of the original intervention and the careful measurement of outcomes. Emerging Models of Acute Care While there is widespread agreement among mental health providers and consumers that treatment should be provided in the least restrictive environment, there is also recognition that, when needed, inpatient services must be available for those in crisis (NAMI, 2011). The continual shrinkage of inpatient psychiatric beds in the United States, which some estimates put at a deficit of nearly 100,000, has caused increases in homelessness and the use of emergency rooms, jails, and prisons as de-facto psychiatric inpatient treatment centers (Bloom, Krishnan, & Lockey, 2008; Treatment Advocacy Center, n.d.). In tandem with efforts to preserve needed inpatient beds are evolving models to provide acute care services to individuals in crisis both within emergency Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E 15 Scope OF Practice of PSYCHIATRIC–MENTAL HEALTH NURSING departments and on small specialty units (Knox, Stanley, Currier, Brenner, Ghahramanlou-Holloway, & Brown, 2012; Kowal, Swenson, Aubry, Marchand, & MacPhee, 2011). The integration of Mental Health Recovery components into all service systems, including into all forms of acute treatment, is now considered vital. Persons in crisis need a safe environment and, as their illness stabilizes, a cul- ture that empowers them to re-engage with life in the community (Tierney & Kane, 2011; Barker & Buchanan-Barker, 2010; Sharfstein, 2009). Consumers, the federal government, and regulators believe that to reach these goals psychiatric services must be recovery-oriented and delivered using a person-centered approach. Since the elements of the recovery framework mirror the Institute of Medicine’s indicators for quality in health services (IOM, 2001), PMH nurses now have a platform for assessing quality in inpatient psychiatric care. This is a welcome expansion of inpatient quality indicators that have centered on limiting restraint and seclusion use in the last decade (Joint Commission, 2010; Stefan, 2006). While restraint reduction is critical, this narrow focus on quality fails to recognize that in addition to a safe environment, individuals with SMI need services that are person-centered and recovery-oriented. As the single largest professional group practicing in inpatient arenas, PMH nurses must provide leadership in constructing recovery-oriented environments and measuring these efforts with tools that capture the social validity of the services provided; e.g., the extent to which the type of help provided in inpatient care is seen as acceptable and having a positive impact in ways that are important to consumers (Ryan et al., 2008). Workforce Requirements for a Public Health Model of Mental Health Care Availability of a mental health workforce with the appropriate skills to implement necessary changes in the healthcare system, as well as appropriate geographic distribution of this workforce, is crucial to improving access and quality. While the overall number of mental health professionals appears ade- quate, rural areas face shortages of clinicians (SAMHSA, 2012). Independent of healthcare reform and its potential to increase access through expansion of health insurance, an estimated 56 million individuals nationally will face difficulties accessing needed health care because of shortages of providers in their communities (National Association of Community Health Centers [NACHC], 2012). 16 Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Scope OF PRACTICE of PSYCHIATRIC–MENTAL HEALTH NURSING Nursing models for rural mental health care specifically address the interplay of poverty, mental disorders, and social issues (Hauenstein, 1997). Such nursing models recognize that resource-poor environments require service models that move clients into self-management and bridge systems so that medical issues are addressed. The need for PMH nurses is great because their command of multiple bodies of knowledge (medical science, neurobiology of psychiatric disorders, treatment methods, and relationship science) positions them as the healthcare professionals best suited to facilitate connections between mental health, primary care, acute care, and case management systems (Hanrahan & Sullivan-Marx, 2005). Given that the supply of psychiatrists is showing only modest increases (Vernon, Salsberg, Erikson, & Kirch, 2009), there is a great need, especially in rural areas, for additional clinicians who can provide psychotherapy, case management, medication management, and a range of other services. PMH- APRNs are prepared to provide a full scope of behavioral health services, including both substance use and mental health services (Funk et al, 2005). However, restrictive reimbursement policies and regulatory barriers associated with scope of practice that limit healthcare consumer access to APRNs must be addressed to achieve access and quality goals. PMH-APRNs need to continue systematic and enhanced data collection on practice and outcomes to document their contribution to quality health care. Several curriculum frameworks have been developed to prepare nurses with the appropriate knowledge and skills to meet future healthcare challenges. Essential PMH competencies have been presented for all practicing RNs (Psychiatric-Mental Health Substance Abuse Essential Competencies Taskforce of the American Academy of Nursing Psychiatric-Mental Health Substance Abuse Expert Panel, 2012). The APNA Recovery to Practice (RTP) curriculum committee is producing a curriculum to integrate recovery into PMH nursing practice, which will be disseminated by SAMHSA as part of the Recovery to Practice initiative. A key aspect of this curriculum development, and of program development in general, is having consumers of these mental health services at the table and contributing to the development of these systems of care (SAMHSA, 2010). Curriculum models should also include the competencies promoted by the Quality and Safety Education for Nurses (QSEN) Institute, which provides “the knowledge, skills and attitudes necessary to continuously improve the quality and safety of the healthcare systems in which they work” (QSEN, n.d.). Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E 17 Scope OF Practice of PSYCHIATRIC–MENTAL HEALTH NURSING A comprehensive blueprint for building the PMH-APRN workforce has been suggested that includes recommendations for how the PMH nursing will increase its numbers and prepare practitioners with the specific competencies needed to build a transformed mental health system (Hanrahan, Delaney, & Stuart, 2012). This workforce plan calls on PMH-APRNs to include the role of individuals in recovery into every aspect of planning and delivery of mental health care. An additional emphasis focuses on expanding the capacity of communities to effectively identify their needs and promote behavioral health and wellness. Indeed, the coming era will demand strong alliances with individuals, families, and communities to build health, recovery, and resilience. Psychiatric-Mental Health Nursing Leadership in Transforming the Mental Health System In the course of their practice, it is critical that PMH nurses consider the particular vision of mental health care that informs their practice. Federal agencies, commissions, and advocacy groups have identified a future vision of a mental healthcare system as person-centered, recovery-oriented, and organized to respond to all consumers in need of services. These reports converge on several points, but most crucial is that a transformed mental health system is centered on the person. Integral in this vision are strategies for remedying the inadequacy and fragmentation of services, and for creating a workforce to carry out the transformation. There is particular emphasis on providing services to children, adolescents, older adults, and other underserved populations. In leading the transformation of the mental healthcare delivery system, PMH nurses must understand the key threads in the government/agency/consumer group plan and the factors that can affect enactment. The transformed mental health system will require nurses who can work between and within systems, connecting services and acting as an important safety net in the event of service gaps. PMH nurses are perfectly positioned to fill this role and make significant contributions to positive clinical recovery outcomes for this vulnerable and often underserved population. Definition of Psychiatric-Mental Health Nursing Nursing’s Social Policy Statement (ANA, 2010) defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.” 18 Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Scope OF PRACTICE of PSYCHIATRIC–MENTAL HEALTH NURSING Psychiatric-mental health nursing is the nursing practice specialty committed to promoting mental health through the assessment, diagnosis, and treatment of behavioral problems, mental disorders, and comorbid conditions across the lifespan. Psychiatric-mental health nursing intervention is an art and a science, employing a purposeful use of self and a wide range of nursing, psychosocial, and neurobiological evidence to produce effective outcomes. PMH nurses work with people who are experiencing physical, psychological, mental, and spiritual distress. They provide comprehensive, person-centered behavioral and psychiatric care in a variety of settings across the continuum of care. Essential components of PMH nursing practice include health and wellness promotion through identification of mental health issues, prevention of mental health problems, care of mental health problems, and treatment of persons with psychiatric disorders, including substance use disorders. Due to the complexity of care in this population, the preferred educational preparation is at the baccalaureate level with credentialing by the American Nurses Credentialing Center (ANCC) or a recognized certification organization. The role of the PMH nurse is to not only provide care and treatment for the healthcare consumer, but also to develop partnerships with healthcare consumers to assist them with their individual recovery goals. These goals may include: renewing hope, redefining self beyond illness, incorporating illness, becoming involved with meaningful activities, overcoming barriers to social inclusion, assuming control, becoming empowered, exercising citizenship, managing symptoms, and being supported by others (Davidson, O’Connell, Sells, & Stacheli, 2003). The PMH nurse has the responsibility to do more for the person when the person can do less, and to do less for the person when he or she is able to do more for him or herself. In this way PMH nurses develop and implement nursing interventions to assist the person in achieving recovery-oriented outcomes (McLoughlin, 2011). This philosophy of directing and providing care when the person is in acute distress and eventually transferring the decision-making and self-care to the individual is rooted in Peplau’s theory of Interpersonal Relations in Nursing (Peplau, 1991). An important focus of PMH nursing involves substance disorders. Just as Schizophrenic Spectrum and Other Psychotic Disorders are described in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), Substance-Related and Addictive Disorders are also described in the DSM as Mental Disorders (American Psychiatric Association, 2013). For example, a healthcare consumer may have a primary mental disorder with a secondary substance-related disorder (e.g., a person diagnosed with bipolar disorder with Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E 19 Scope OF Practice of PSYCHIATRIC–MENTAL HEALTH NURSING hypomanic symptoms who uses alcohol to slow down); or, a person may have a primary substance disorder with a secondary mental disorder, (e.g., a person who is addicted to cocaine and becomes suicidal as a result of the cocaine use), or a person may have two primary disorders such as schizophrenia and alcohol addiction. The Substance Abuse and Mental Health Services Administration (SAMHSA) has long advocated for integrated treatment of both mental and substance disorders (U.S. Health and Human Services, 2005). Thus, in the first example, if a healthcare consumer was admitted to a hospital with symptoms of hypomania, the PMH-RN would not only need to assess and treat the symptoms related to mania, but would also need to assess the consumer for alcohol use and treatment that might include detoxification. Therefore, the PMH-RN requires competency in assessment and treatment of both disorders. Further, PMH nurses provide basic care and treatment, general health teaching, health screening, and appropriate referral for treatment of general or complex physical health problems (Kane & Brackley, 2011; Haber & Billings, 1995). The PMH nurse’s assessment synthesizes information obtained from interviews, behavioral observations, and other available data. From these, the PMH nurse determines diagnoses or problems that are congruent with available and accepted classification systems. This synthesis and development of a problem or area of focus differentiates the PMH nurse from others who work as nursing staff who may gather data for the PMH nurse. Next, personal goals or outcomes are established, with the individual directing this process as much as possible. Finally, the nurse and the healthcare consumer develop a treatment plan based on assessment data and the healthcare consumers’ goals. The PMH nurse then selects and implements interventions to assist a person in achieving their recovery goals and periodically evaluates both attainment of the goals and the effectiveness of the interventions. Use of standardized classification systems enhances communication and permits the data to be used for research. However, in keeping with person-centered, recovery-oriented practice, the goal/outcome development must be individualized as much as possible, ideally with the consumer developing her or his own goals with assistance from the PMH nurse (Adams & Grieder, 2005; McLoughlin & Geller, 2010). Mental health problems and psychiatric disorders are addressed across a continuum of care. A continuum of care consists of an integrated system of settings, services, healthcare clinicians, and care levels spanning health states from illness to wellness. The primary goal of a continuum of care is to provide 20 Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Scope OF PRACTICE of PSYCHIATRIC–MENTAL HEALTH NURSING treatment that allows the individual to achieve the highest level of functioning in the least restrictive environment. Phenomena of Concern for Psychiatric-Mental Health Nurses Phenomena of concern for psychiatric-mental health nurses are dynamic, exist in all populations across the lifespan and include but are not limited to: Promotion of optimal mental and physical health and well-being Prevention of mental and behavioral distress and illness Promotion of social inclusion of mentally and behaviorally fragile individuals Co-occurring mental health and substance use disorders Co-occurring mental health and physical disorders Alterations in thinking, perceiving, communicating, and functioning related to psychological and physiological distress Psychological and physiological distress resulting from physical, interpersonal, and/or environmental trauma or neglect Psychogenesis and individual vulnerability Complex clinical presentations confounded by poverty and poor, inconsistent, or toxic environmental factors Alterations in self-concept related to loss of physical organs and/or limbs, psychic trauma, developmental conflicts, or injury Individual, family, or group isolation and difficulty with interpersonal relations Self-harm and self-destructive behaviors including mutilation and suicide Violent behavior including physical abuse, sexual abuse, and bullying Low health literacy rates contributing to treatment non-adherence Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E 21 Scope OF Practice of PSYCHIATRIC–MENTAL HEALTH NURSING Psychiatric-Mental Health Nursing Clinical Practice Settings Psychiatric-mental health registered nurses practice in a variety of clinical settings across the care continuum and engage in a broad array of clinical activities including but not limited to health promotion and health maintenance; intake screening, evaluation, and triage; case management; provision of therapeutic and safe environments; promotion of self-care activities; administration of psychobiological treatment regimens and the monitoring of response and effects; crisis intervention and stabilization; and psychiatric rehabilitation, or interventions that assist in a person’s recovery. PMH nurses may be paid for their services on a salaried, contractual, or fee-for-service basis. In the 21st century, advances in the neurosciences, genomics, and psychopharmacology, as well as evidenced-based practice and cost-effective treatment, enable the majority of individuals, families, and groups in need of mental health services to be cared for in community settings. Acute, intermediate, and long- term care settings still admit and care for healthcare consumers with behavioral and psychiatric disorders. However, lengths of stay, especially in acute and intermediate settings, have decreased in response to fiscal mandates, the availability of community-based settings, and consumer preference. Crisis Intervention and Psychiatric Emergency Services One of the most challenging clinical environments in psychiatric nursing is the psychiatric emergency department. Emergency departments are fast- paced, often overstimulating environments, with typically limited resources for those individuals with psychiatric and/or substance-related emergencies. Psychiatric emergency service can be based in a hospital or a community. The specific models of care continue to evolve and develop based on identified local health care needs. The current models in dealing with psychiatric emergencies include consultative services in a medical center or hospital emergency department (these psychiatric services may either be internally based or externally contracted); an enhanced, autonomous psychiatric emergency department; extended observation units; crisis stabilization units; respite services; and mobile crisis teams (Glick, Berlin, Fishkind, & Zeller, 2008). Extended observation units, crisis stabilization units, respite service, and mobile crisis teams are alternative treatment options for individuals with a psychiatric emergency or crisis that does not require inpatient psychiatric treatment. 22 Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Scope OF PRACTICE of PSYCHIATRIC–MENTAL HEALTH NURSING Acute Inpatient Care This setting involves the most intensive care and is reserved for acutely ill healthcare consumers who are at imminent risk for harming themselves or others, or are unable to care for their basic needs because of their level of impairment. This treatment is typically short-term, focusing on crisis stabilization. These units may be in a psychiatric hospital, a general care hospital, or a publicly funded psychiatric facility. Intermediate and Long-Term Care Intermediate and long-term care psychiatric facilities may admit patients directly but more often receive patients transferred from acute care settings. Intermediate and long-term care provides treatment, habilitation, and rehabilitation for patients who are at chronic risk for harming themselves or others due to mental disorders or who are unable to function with less intense supervision and support. Long-term inpatient care usually involves a minimum of 3 months. Both public and private psychiatric facilities provide this type of care. Long-term care hospitals also include state hospitals that admit patients through the criminal justice system. Often these forensic patients must remain in locked facilities for long periods of time; this is related to state statutes and legal statuses rather than clinical status. Partial Hospitalization and Intensive Outpatient Treatment The aim of partial hospitalization and intensive outpatient programs is acute symptom management and stabilization with safe housing options. Partial hospitalization and intensive outpatient treatment programs admit healthcare consumers who are in acute need of treatment but do not require 24-hour medical management or 24-hour nursing care. These programs function as free-standing programs and also serve as step-down programs for patients discharged from inpatient units. Residential Services A residential facility provides 24-hour care and housing for an extended period of time. Services in typical residential treatment facilities include psychoedu- cation for symptom management and medications, assistance with vocational training, and, in the case of the severely and persistently mentally ill, training for daily activities. Independent living is often a goal for occupants of residential treatment facilities. Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E 23 Scope OF Practice of PSYCHIATRIC–MENTAL HEALTH NURSING Community-Based Care Psychiatric-mental health registered nurses provide care within the community as an effective method of responding to the mental health needs of individuals, families, and groups. Community-based care refers to all non-hospital or facility-based care, and therefore may include care delivered in partnership with healthcare consumers in their homes, worksites, mental health clinics and programs, health maintenance organizations, shelters and clinics for the homeless, crisis centers, senior centers, group homes, and other community settings. Schools and colleges are an important site of mental health promotion, primary prevention, and early intervention programs for children and youth that involve psychiatric-mental health registered nurses. Psychiatric- mental health registered nurses are involved in educating teachers, parents, and students about mental health issues and in screening for depression, suicide risk, post-traumatic stress disorder, and alcohol, substance, and tobacco use. Assertive Community Treatment (ACT) ACT is a team treatment approach designed to provide comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with SMI (Assertive Community Treatment Association, 2012). An ACT team is comprised of a group of professionals whose background and training include social work, rehabilitation, peer counseling, nursing, and psychiatry. The ACT approach provides highly individualized services directly to consumers 24 hours a day, 7 days a week, and 365 days a year. A 2003 study on ACT teams found that a full-time nurse was rated as the most important member of an ACT team (McGrew, Pescosilido, & Wright, 2003). Levels of Psychiatric-Mental Health Nursing Practice There are two levels of practice. The first level of PMH practice is that of the psychiatric-mental health registered nurse (PMH-RN), with educational preparation within a bachelor’s degree, associate’s degree, or a diploma program. This level is discussed in the next section. The next level of PMH practice is that of the psychiatric-mental health advanced practice registered nurse (PMH-APRN) with educational preparation within a master’s degree or doctoral degree program. That level is discussed starting on pg. page 27. Further, two sub-categories exist at the advanced practice register nurse level: the psychiatric-mental health mental clinical nurse specialist (PMHCNS) and the psychiatric-mental health nurse practitioner (PMHNP). The Doctor of Nursing Practice (DNP) as described by the American Association of Colleges 24 Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Scope OF PRACTICE of PSYCHIATRIC–MENTAL HEALTH NURSING of Nursing (AACN, 2004) has advanced education in systems function, analysis, health policy, and advocacy. Nurses with the doctor of nursing practice degree may be at the PMH-RN level (e.g., RN administrators or educators) or at the APRN level (e.g., clinical nurse specialists or nurse practitioners). Psychiatric-Mental Health Registered Nurse (PMH-RN) A psychiatric-mental health registered nurse (PMH-RN) is a registered nurse who demonstrates competence—including specialized knowledge, skills, and abilities—obtained through education and experience in caring for persons with mental health issues, mental health problems, psychiatric disorders, and co-occurring psychiatric and substance use disorders. The science of nursing is based on a critical thinking framework, known as the nursing process, composed of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. These steps serve as the foundation for clinical decision making and are used to provide an evidence base for practice (ANA, 2010). Psychiatric-mental health registered nursing practice is characterized by the use of the nursing process to treat people with actual or potential mental health problems, psychiatric disorders, and co-occurring psychiatric and substance use disorders. This nursing process is meant to promote and foster health and safety; assess dysfunction and areas of individual strength; assist persons to achieve their own personal recovery goals by gaining, re-gaining, or improving coping abilities, living skills, and managing symptoms; maxi- mize strengths; and prevent further disability. Data collection at the point of contact involves observational and investigative activities, which are guided by the nurse’s knowledge of human behavior and the principles of the psychiatric interviewing process. The data may include but are not limited to the healthcare consumer’s: Central complaint, focus, or concern and symptoms of major psychiatric, substance related, and medical disorders Strengths, supports, and individual goals for treatment History and presentation regarding suicidal, violent, and self- mutilating behaviors History of ability to seek professional assistance before engaging in behaviors dangerous to self or others Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E 25 Scope OF Practice of PSYCHIATRIC–MENTAL HEALTH NURSING History of reasons why it may have been difficult in the past to follow- through with suggested or prescribed treatment Pertinent family history of psychiatric disorders, substance abuse, and other mental and relevant physical health issues Evidence of abuse, neglect, or trauma Stressors, contributing factors, and coping strategies Demographic profile and history of health patterns, illnesses, past treatments, and difficulties and successes in follow-through Actual or potential barriers to adherence to recommended or prescribed treatment Health beliefs and practices Methods of communication Religious and spiritual beliefs and practices Cultural, racial, and ethnic identity and practices Physical, developmental, cognitive, mental, and emotional health concerns, as well as neurological assessment Daily activities, personal hygiene, occupational functioning, functional health status, and social roles Work, sleep, and sexual functioning Economic, political, legal, and environmental factors affecting health Significant support systems and community resources, including those that have been available and underutilized Knowledge, satisfaction, and motivation to change, related to health Strengths and competencies that can be used to promote health Employment and military service Current and past medications, both prescribed and over-the-counter, including herbs, alternative medications, vitamins, or nutritional supplements 26 Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Scope OF PRACTICE of PSYCHIATRIC–MENTAL HEALTH NURSING Medication interactions and history of side effects and past effectiveness Allergies and other adverse reactions History and patterns of alcohol, substance, and tobacco use, including type, amount, most recent use, and withdrawal symptoms Complementary therapies used to treat physical and mental disorders and their outcomes The work of psychiatric-mental health registered nurses is accomplished through the interpersonal relationship, therapeutic intervention skills, and professional attributes. These attributes include but are not limited to self- awareness, empathy, and moral integrity, which enable psychiatric-mental health nurses to practice the artful use of self in therapeutic relationships. Some characteristics of artful therapeutic practice are respect for the person or family, availability, spontaneity, hope, acceptance, sensitivity, vision, accountability, advocacy, and spirituality. Psychiatric-mental health registered nurses play a significant role in the articulation and implementation of new paradigms of care and treatment that place the healthcare consumer at the center of the care delivery system. PMH- RNs are key members of interdisciplinary teams in implementing initiatives such as fostering the development of person-centered, trauma-informed care environments in an effort to promote recovery and reduce or eliminate the use of seclusion or restraints; promoting individually-driven, person-centered treatment planning processes; and, developing skill-building programs to assist individuals to achieve their own goals. Psychiatric-mental health registered nurses maintain current knowledge of advances in genetics and neuroscience and their impact on psychopharmacology and other treatment modalities. In partnership with healthcare consumers, communities, and other health professionals, psychiatric-mental health nurses provide leadership in identifying mental health issues and in developing strategies to ameliorate or prevent them. Psychiatric-Mental Health Advanced Practice Registered Nurse (PMH-APRN) The American Nurses Association (ANA) defines advanced practice registered nurses (APRNs) as professional nurses who have successfully completed a Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E 27 Scope OF Practice of PSYCHIATRIC–MENTAL HEALTH NURSING graduate program of study in a nursing specialty that provides specialized knowledge and skills that form the foundation for expanded roles in health care. The psychiatric-mental health advanced practice registered nurse is edu- cated at the master’s or doctoral level with the knowledge, skills, and abilities to provide continuous and comprehensive mental health care, including assessment, diagnosis, and treatment across settings. Psychiatric-mental health advanced practice nurses (PMH-APRN) include both nurse practitioners (PMH-NP) and clinical nurse specialists (PMH-CNS). Psychiatric-mental health advanced practice registered nurses are clinicians, educators, consultants, and researchers who assess, diagnose, and treat individuals and families with behavioral and psychiatric problems and disorders or the potential for such disorders. Psychiatric-mental health nursing is necessarily holistic and considers the needs and strengths of the individual, family, group, and community. APRNs play a pivotal role in the future of health care. Often primary care providers, they are at the forefront of providing preventive care to the public (ANA, n.d.1) ). Demand for healthcare services will continue to grow as mil- lions of Americans gain health insurance under the Affordable Care Act and baby boomers dramatically increase Medicare enrollment. The nation will call on APRNs to meet these needs and participate as key members of healthcare teams (ANA, n.d.2). Consensus Model: LACE (Licensure, Accreditation, Certification and Education) and APRN Roles The Consensus Model for Advanced Practice Registered Nurse (APRN) Regulation—focusing on licensure, accreditation, certification, and education (LACE)—was completed in 2008 by the APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee. Broadly, the model identifies four APRN roles for which to be certified: clinical nurse specialist (CNS), certified nurse practitioner (CNP), certified registered nurse anesthetist (CRNA), and certified nurse midwife (CNM). Each of these roles involves specialized graduate educational preparation that can be applied to a focused population. Finally, a nurse must demonstrate specific competencies as outlined by her or his practice area (NCSBN Joint Dialogue Group Report, 2008). Unlike other areas in nursing, the roles of a PMH-CNS and PMH-NP are virtually synonymous. In 2007, American Psychiatric Nurses Association (APNA) and the American Nurses Credentialing Center (ANCC) conducted a logical job analysis that described the purpose, essential functions, setting, and 28 Psychiatric–Mental Health Nursing: Scope and Standards of Practice, 2E Scope OF PRACTICE of PSYCHIATRIC–MENTAL HEALTH NURSING qualifications needed to perform as a PMH-CNS or a PMH-NP. This analysis confirmed that the vast commonalities in practice warranted the development of one advanced practice examination for both roles (Rice, Moller, DePascale, & Skinner, 2007). With mental health parity and other healthcare reforms, PMH-CNSs and PMH-NPs play key roles in the integration of physical and mental health care and treatment in both hospital and community settings. All APRNs are educationally prepared to provide a scope of services to a population across the continuum of care as defined by nationally recognized role and population-focused competencies; however, the emphasis and implementation within each APRN role varies based on care needs (NCSBN Joint Dialogue Group Report, 2008) The full scope and standards of practice for psychiatric-mental health advanced practice nursing is set forth in this document. While individual PMH-APRNs may actually implement portions of the full scope and practice based on their role, position description, and practice setting, the full breadth of the knowledge base informs their practice. PMH-APRN practice focuses on the application of competencies, knowledge, and experience to individuals, families, or groups with complex psychiatric-mental health problems. Promoting mental health in society is a significant role for the PMH-APRN, as is collaborati

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